an adult client is undergoing weekly external radiation treatments for breast cancer and reports increasing fatigue what action should the nurse take
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Nursing Elites

HESI LPN

HESI PN Exit Exam 2023

1. An adult client is undergoing weekly external radiation treatments for breast cancer and reports increasing fatigue. What action should the nurse take?

Correct answer: D

Rationale: The correct action for the nurse to take when a client undergoing radiation treatment for breast cancer reports increasing fatigue is to reinforce the need for extra rest periods and plenty of sleep. Fatigue is a common side effect of radiation therapy, and adequate rest and sleep can help manage this symptom. Notifying the healthcare provider or charge nurse immediately (choice A) is not necessary for increasing fatigue, as it is expected during radiation therapy. Offering to reschedule the treatment for the following week (choice B) is not the best initial action for managing fatigue. Planning to monitor the client's vital signs every 30 minutes (choice C) is unnecessary and not directly related to managing fatigue caused by radiation therapy.

2. What is the most common sign of a localized infection?

Correct answer: C

Rationale: The correct answer is C: Redness, warmth, and swelling at the site of infection. These signs are typical indications of a localized infection, representing inflammation and the body's immune response to the pathogen. Fever (choice A) is a systemic response and not specific to a localized infection. Elevated white blood cell count (choice B) can be seen in both localized and systemic infections. Chills and shivering (choice D) are more related to the body's response to fever and not specifically indicative of a localized infection.

3. A client who had a left hemicolectomy is experiencing a low-grade fever on post-operative day three. What is the nurse's best action?

Correct answer: A

Rationale: A low-grade fever on post-operative day three can be a sign of atelectasis, a common post-operative complication. Encouraging deep breathing and the use of the incentive spirometer can help prevent and treat this condition. Atelectasis is often due to shallow breathing, so option A is the best initial action to promote lung expansion. Administering antipyretic medication (option B) may help reduce the fever but does not directly address the underlying cause. Notifying the healthcare provider immediately (option C) is not necessary at this point unless other concerning symptoms are present. Increasing the client’s fluid intake (option D) is important for overall recovery but is not the priority in this scenario.

4. A client who had a hip replacement is being prepared for discharge. What should the nurse include in the discharge teaching to prevent hip dislocation?

Correct answer: A

Rationale: The correct answer is A: 'Avoid crossing your legs at the knees or ankles.' Crossing legs at the knees or ankles can cause excessive stress on the new hip joint, leading to a risk of dislocation. Choice B is incorrect because sleeping on the side of the operated hip can also increase the risk of dislocation. Choice C is incorrect as sitting in low chairs with knees higher than hips is a recommended position to prevent hip dislocation. Choice D is incorrect because bending forward at the waist to pick up objects can strain the hip joint and increase the risk of dislocation.

5. An older male client with Alzheimer's disease is admitted to an extended care facility. Which intervention should the PN include in the client's nursing care plan?

Correct answer: A

Rationale: The correct intervention for a client with Alzheimer's disease in an extended care facility is to plan to have the same nursing staff provide care whenever possible. Consistency in caregivers helps reduce confusion and anxiety in clients with Alzheimer’s disease, promoting a stable and supportive environment for the client. Choice B is incorrect as it focuses on activities rather than the consistency of caregivers. Choice C is incorrect as it suggests isolating the client, which can lead to increased confusion and distress. Choice D is incorrect as introducing the client to new people immediately can be overwhelming and may exacerbate their symptoms.

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